Directorate of Education and Quality School of Postgraduate Medicine Visit to Hinchingbrooke Health Care NHS Trust Visit Report 28 th HEEoE representatives: Dr Ian Cooper, School of Medicine Quality Lead Chair Dr Ian Barton, Head of School Sue Agger, Senior Deanery Quality and Academic Training Manager Trust representatives : Number of trainees & grades who were met: Dr Mark Lillicrap Director of Postgraduate Education Dr Singhan Krishnan RCP College Tutor Ms Michaela Turner-Douglas Medical Education Manager Mr Hisham Abdel- Rahman Chief Executive CMT x 1 x 3 ST3+ x 4 (Specialties included gastroenterology, respiratory medicine and rheumatology. See separate report for cardiology) Summary (including recommendation of posts by trainees) The visiting team found that the training of junior doctors in medical specialties was generally of a high standard and there are good training opportunities. This was recognised and appreciated by the trainees themselves. Most would be happy to recommend their posts to a colleague. There have been improvements in the ability to fill vacancies with locum staff. This appears to have led to improvement in workload, clinical supervision and the overall satisfaction of trainees. There is a well-defined structure to the management of medical education within the organisation. The Trust appears to take medical education seriously and have developed mechanisms to provide quality assurance up to board level. Training and appraisal of educational supervisors is systematic and of a high standard. Examples of Good Practice 1. The timetabled week of outpatient clinics for CMTs. Trainees are able 1 of 9
to select the specialty clinics they wish to attend. There are no other commitments for that week. One trainee with an interest in a specialty clinic not available locally, was able to spend time at another hospital to gain additional experience. 2. Educational supervision Educational supervisors receive training in key AoME/GMC domains. CPD in medical education is supported. Educational supervisors are allocated 0.25 PAs per trainee. Educational supervisor performance is monitored and this forms part of their appraisal. Education is a standing item on the Board agenda. Actions required by visiting team and timeframe The Trust must provide a written action plan to meet the following requirements by January 31 2015 Mandatory: 1. The additional locum junior doctor post on Juniper Ward should be made permanent, and there should never be less than two sub-str juniors on the gastroenterology firm responsible for the patients on that ward. 2. Medical registrars who intend to dually accredit in their specialty and GIM must have a clinical supervisor for each. This could be the same person if such an individual is themselves practicing both. Recommendations: 1. The ease of access to guidelines on the intranet should be improved 2. There should meetings of educational value in each department which allow StRs to learn more about their specialty. These need not be formal teaching sessions, but could take the form of development of local audits and guidelines at a team level. 3. A group should be set up with the intention of improving the electronic discharge summary software. This should include modification to enable doctors to begin writing discharge summaries in advance of patients discharge. Planned re-visit date The posts are approved for a further three years. Revisit is planned in 2017. 2 of 9
RELATED EVIDENCE Previous School of Medicine visits (dates and summaries) 1 December 2011 Actions required: Improvement of handover Investigation of undermining behaviour by staff in radiology Ensure attendance of trainers at CMT teaching sessions Reduce the vacancy rates in medical posts Ensure opportunities for outpatient attendance for CMTs Allocation of PAs for clinical supervision Establishment of a medical faculty group Careers support should be provided. Previous DPQR (date and summary for Medicine) 29 November 2012 Provision of medical education was compliant 2014 GMC Trainee Survey outliers 2014 trainee survey: Specialty Red outliers Green Outliers CMT Clinical supervision Overall satisfaction Clinical supervision Work load Adequate experience Access to educational resources 2014 GMC Trainee Survey patient safety concerns and free text comments from Medicine There were none 3 of 9
OTHER ACTIVITIES Appointment of RCP College Tutor The visiting team, along with the Clinical Tutor interviewed Dr Anita Gibbons and were pleased to offer her the post of College Tutor to be taken up in January 2015. The team expressed gratitude for the excellent work undertaken by Dr Singhan Krishnan in his current role as RCP College Tutor. MEETINGS WITH TRAINEES (1 OF 2) Trainee Group Number of trainees met CMT and s CMT - 1-3 Domain 1: Patient safety Adequacy of clinical supervision: This is good both in and out of hours. Consultants are readily available for advice, whenever needed. Critically ill patients: There were no concerns about patient safety in this group of patients Safety of rota patterns and effectiveness of handover: The evening handover in AAU is formal and effective. The morning AAU handover is less formal and precedes the post-take ward round. There is a nightly informal hand over of ward patients to the out of hours team. At the weekend a formal handover list of sick patients is compiled for the out of hours team. Domain 5: Delivery of approved curriculum Adequacy of clinical (including outpatient) experience: All trainees in this group were happy with the case-mix and quantity of clinical experience in all areas of general medicine. The dedicated and timetabled week of out-patient clinics is an effective way of delivering training opportunities in this area. One trainee proclaimed, The clinic week is great Adequacy of content of individual programmes: The provision of training for both CMT and appears to be adequate. Quality of internal formal teaching: Formal teaching is accessible and of good quality. CMT teaching is at 1300 on a Wednesday. teaching is a half day on Wednesday afternoon. Trainees were able to attend the half day teaching without difficulty. CMTs have been involved in organising their own teaching. Medical registrars have been helpful in providing training in practical procedures. Ability to attend internal and external training courses etc. including accessibility of study leave: Trainees reported no difficulty in taking study leave when needed. Accessibility of assessments including WPBAs: There was no difficulty in obtaining assessments Adequacy of feedback: 4 of 9
This was reported as good. There is clearly good communication within medical teams and with consultants. Domain 6: Support and development of trainees, trainers and local faculty Arrangements for Trust induction (including for intermediate starters): All trainees received Trust induction. It was reported that this was also available for those starting out of phase. Arrangements for departmental induction (including for intermediate starters): This is provided to all trainees. In addition there is a Junior Doctors Handbook which is given to all trainees. It is also available on the intranet and is regularly updated. Quality of educational supervision (including appropriate use of eportfolio): This was good. However there may be some anomalies as one GP trainee reported that they did not actually work with their clinical supervisor. Quality of careers support: Not investigated Intensity and educational content of work and adequacy of learning opportunities (including audit): Work intensity was reported to be appropriate except in one area. We heard that the gastroenterology firm responsible for patients on Juniper Ward was too busy. Regularly, one sub-str junior doctor was responsible for the care of more than twenty patients. The Trust had responded to concerns by appointing a second junior to a locum post. Because of this issue one of the trainees would not recommend their post to a colleague. Trainees reported that clinical guidelines are hard to find on the intranet. We did not examine this at first hand, but we heard that the indexing of guidelines was not very user-friendly. However, the availability of the Junior Doctors Handbook on the intranet meant that trainees rarely needed to look further for what they needed. Experience of bullying and harassment, awareness of whistle-blowing policy: No one had any knowledge or experience of bullying or harassment. Support from postgraduate education team and pastoral support: This is good. The Education Centre has recently been relocated to newly refurbished accommodation. Domain 7: Management of education and training Awareness of how to access additional support: Trainees reported that problems were listened to and addressed. The Stop the Line procedure is invoked and appears to function as it should. Domain 9: Outcomes Trainee progression and examination achievements: Examination success rates for CMT is very good. 5 of 9
MEETINGS WITH TRAINEES (2 OF 2) Trainee Group Specialty Registrars Domain 1: Patient safety Adequacy of clinical supervision: Excellent supervision by consultants Number of trainees met ST3+ - four trainees (Specialties included gastroenterology, respiratory medicine and rheumatology. See separate report for cardiology) Safety of rota patterns and effectiveness of handover: Post-take ward rounds were reported to be of good quality and educational. Domain 5: Delivery of approved curriculum Adequacy of clinical (including outpatient) experience: One trainee had been concerned that coming to Hinchingbrooke may not provide sufficient numbers for her GIM training. The clinical workload was described as not too busy and was very manageable. The visiting team are of the opinion that there are sufficient numbers of medical admissions to comply with requirements.. Adequacy of content of individual programmes: The training in gastroenterology was highlighted as being particularly good. One trainee had returned to the Trust for more training at a senior level having worked here earlier in her rotation. Quality of internal formal teaching: There is no formal teaching specifically for StR grades. However there are good opportunities for StRs to provide teaching to more junior colleagues and to acquire feedback I the process. Ability to attend internal and external training courses etc. and accessibility of study leave: We heard that it was easy to take study leave Accessibility of assessments including WPBAs: We heard that these were easy to obtain Adequacy of feedback: Trainees work closely with their senior colleagues and receive good feedback. Domain 6: Support and development of trainees, trainers and local faculty Arrangements for Trust induction (including for intermediate starters): No problems identified Arrangements for departmental induction (including for intermediate starters): The close working relationships with consultants ensures that this occurs Quality of educational supervision (including appropriate use of eportfolio): Educational supervision was reported to be good and meeting occurred regularly. Intensity and educational content of work and adequacy of learning opportunities: 6 of 9
This is generally good. Problems relating to the busy workload on Juniper Ward were mentioned and supported the views reported by the other group of junior doctors. However the workload for StRs on this ward was not too great. Experience of bullying and harassment, awareness of whistle-blowing policy: None reported Opportunities for academic training: Not discussed Support from postgraduate education team and pastoral support: This was good Domain 7: Management of education and training Awareness of how to access additional support: No concerns Domain 9: Outcomes Trainee progression and examination achievements: No concerns. One trainee stated that Hinchingbrooke was very, very good for registrars 7 of 9
MEETINGS WITH TRAINERS AND LEP TEAM Domain 1: Patient safety Processes for clinical supervision: Clinical supervision is good at all times. There is consultant presence in the evening and at weekends, although there is no continuous twelve hour presence of consultants at the weekend. Design of rota patterns and handover processes: Consultants are familiar with the handover processes which appear to work well Work intensity: It was reported that the respiratory ward and the short stay wards were busy with some teams occasionally responsible for the care of 30-40 patients. Domain 2: Quality Management Provision of information for Deanery Quality Management Processes: This was completed and was available to the visiting team. Evidence was provided that the Trust had addressed concerns raised by the most recent GMC survey. Domain 5: Delivery of approved curriculum including assessment Knowledge of curriculum, training in use of portfolio and training in completing assessments including WPBAs objectively: Training of educational supervisors is undertaken according to AoME/GMC domains Teaching programmes: There are regular teaching sessions throughout the week. PACES teaching is delivered by Dr Borland and medical StRs on an ad hoc basis depending on need. Outpatient attendance: The recently introduced out-patient week is working well, provides good experience for CMT trainees and is very popular Domain 6: Support and development of trainees, trainers and local faculty Arrangements for Trust and departmental induction (including for intermediate starters): There is one day of Trust induction. This is followed by a Department of Medicine induction when trainees are provided with copies of the Junior Doctor Handbook. The reliance on locum doctors has presented some difficulties with induction for this group of staff. In view of this consultants often have to undertake out patient clinics without registrar support. Training for clinical and educational supervisors: This appears to be structured and of high quality Careers support: Not discussed Identification of time for educational activities in job plans: The Trust allocates 0.25 PAs per trainee for educational supervision Support from postgraduate education team: Good 8 of 9
Domain 7: Management of education and training Support at Trust Board level: Education is a standing item on the Board Agenda. Currently the CEO takes responsibility for education at board level. There will soon be a new Medical Director who will then assume this responsibility. Support at Departmental Level: Both the Director of Medical Education and the College Tutor are fully involved with the management of medical education for trainees in medical specialties and have provided evidence of continued improvement in the standards of medical education. The visiting team were impressed that the voice of the trainees was heard and that changes may occur as a consequence. 9 of 9